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GUDFALA TUT SKUL PROJEK

2018

Project partners:

Medical Sailing Ministries, PCV Health, Shefa Health, Vanuatu Ministry of Health, Dentalife Australia,

Central School (Port Vila)

Funding:

Medical Sailing Ministries, Dentalife Australia

Project Design:

Barry Stewart, Robert Latimer, Mike Clarke, Andrew Stray

Project location:

Central School, Port Vila

Dental Team:

Leaders: Barry Stewart, Richard Tatwin

Examiners: Dr Barry Stewart, Dr Jenny Stephens, Lilirose Dan, Dr Gaddi Hurison

Recorders: Premilla H Mera, Annette Vincent, Dr Jenny Stephens, Nicola Young

Questionnaire interviewers: Bob Natuman, Morinda Kalmar (nee Toara), Rafina Daniel, Dick Naket, Dr

Christopher Roberts

Project supervisors: Bob Natuman, Morinda Toara

Data entry:

Liz Mallen, Mike Clarke

Data analysis:

Dr Wael Sabbah, Mike Clarke

Principal author:

Dr Barry Stewart

Co-authors:

Mike Clarke, Dr Wael Sabbah, Robert Latimer, Dr Jenny Stephens

Acknowledgements:

Mr Andrew Stray (Director, Dentalife Australia), Dr Maine Rezel (Dental officer-in-charge, Vila Central

Hospital, dental clinic), Mr Paul Alex Hetyey (Principal, Central School), Vatoko family

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CONTENTS

ABBREVIATIONS/TERMINOLOGY ………………………………………………………………………………………………………………….. 4

SUMMARY ………………………………………………………………………………………………………………………………………………………… 5

1. INTRODUCTION …………………………………………………………………………………………………………………………………… 6

1.1. BACKGROUND AND RATIONALE ………………………………………………………………………………………………………………….. 6

1.2. TOOTHPASTE DEVELOPMENT ……………………………………………………………………………………………………………………… 7

INTRODUCTION ……………………………………………………………………………………………………………………………………….. 7

FLAVOURS AND COLOURS ……………………………………………………………………………………………………………………….. 8

DISPENSERS ……………………………………………………………………………………………………………………………………………… 8

ADJUNCTIVE PROJECT ………………………………………………………………………………………………………………………………. 8

2. MATERIALS AND METHODS ………………………………………………………………………………………………………………… 9

2.1. CHOICE OF SCHOOL ………………………………………………………………………………………………………………………………….. 9

2.2. SELECTION OF AGE GROUPS …………………………………………………………………………………………………………………….. 9

2.3. PRELIMINARY PLANNING …………………………………………………………………………………………………………………………. 9

2.4. THE DENTAL TEAM …………………………………………………………………………………………………………………………………… 9

2.5. MATERIALS – RECORDING PLAQUE AND QUESTIONNAIRES ……………………………………………………………………… 9

2.6. MATERIALS – FOR CLASSROOM ……………………………………………………………………………………………………………….. 10

2.7. MATERIALS - FOR HOME ………………………………………………………………………………………………………………………….. 10

2.8. TRAINING – DENTAL TEAM ………………………………………………………………………………………………………………………. 11

2.9. TOOTHPASTE MANUFACTURE …………………………………………………………………………………………………………………. 12

2.10. TOOTHPASTE INGREDIENTS …………………………………………………………………………………………………………………….. 13

2.11. INSTRUCTIONS TO CHILDREN AND CLASS TEACHERS …………………………………………………………………………………. 13

2.12. PRE-EXAMINATION PROCEDURE ……………………………………………………………………………………………………………… 14

2.13. EXAMINATION …………………………………………………………………………………………………………………………………………. 14

2.14. POST EXAMINATION ……………………………………………………………………………………………………………………………….. 14

2.15. MAINTENANCE PHASE …………………………………………………………………………………………………………………………….. 14

3. RESULTS …………………………………………………………………………………………………………………………………………….. 15

3.1. NUMBER OF TRIAL PARTICIPANTS ………………………………………………………………………………………………………………. 15

3.2. PLAQUE SCORES …………………………………………………………………………………………………………………………………………. 16

3.3. CLASS 1A (NON-INTERVENTION GROUP) …………………………………………………………………………………………………… 20

3.4. QUESTIONNAIRES ………………………………………………………………………………………………………………………………………. 22

4. SHORTCOMINGS Of DATA COLLECTION ……………………………………………………………………………………………… 27

4.1. VARIATIONS IN EXAMINERS ……………………………………………………………………………………………………………………….. 27

4.2. SAMPLE SIZE ………………………………………………………………………………………………………………………………………………. 27

4.3. ATTRITION OF TRIAL PARTICIPANTS ……………………………………………………………………........................................ 27

4.4. TRANSLATION OF QUESTIONNAIRES INTO BISLAMA …………………………………………………………………………………… 27

5. DISCUSSION ……………………………………………………………………………………………………………………………………….. 28

5.1. PLAQUE SCORES …………………………………………………………………………………………………………………………………………. 28

5.2. QUESTIONNAIRES ………………………………………………………………………………………………………………………………………. 29

CHILDREN’S PERCEIVED HEALTH OF TEETH AND GUMS ……………………………………………………………………………. 29

TOOTHACHE EXPERIENCE ………………………………………………………………………………………………………………………… 30

RATING OF TRIAL TOOTHPASTE ………………………………………………………………………………………………………………. 30

BRUSHING FREQUENCY …………………………………………………………………………………………………………………………… 31

TOOTHPASTE SAMPLES FOR CLASS 1B PARENTS ……………………………………………………………………………………… 31

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CHANGING FAMILY ORAL HEALTH HABITS ………………………………………………………………………………………………. 31

5.3. THE CASE FOR SUPERVISED TOOTH BRUSHING WITH FLUORIDE TOOTHPASTE IN SCHOOLS ……………………….. 32

6. RECOMMENDATIONS ………………………………………………………………………………………………………………………… 34

7. CONCLUSIONS …………………………………………………………………………………………………………………………………… 34

APPENDICES ……………………………………………………………………………………………………………………………………. 35-55

REFERENCES ……………………………………………………………………………………………………………………………………… 56

LIST OF FIGURES

FIGURE 1: DISTRIBUTION OF MEAN PLAQUE SCORES BY CLASS AND WEEK ……………………………………………………… 16

FIGURE 2: PLAQUE INDEX BY GENDER …………………………………………………………………………………………………………….. 20

FIGURE 3: DISTRIBUTION OF MEAN PLAQUE SCORES BY CLASS AND WEEK VERSUS CLASS 1A …………………………. 21

LIST OF TABLES

TABLE 1: NUMBER OF TRIAL PARTICIPANTS ………………………………………………………………………………………….. 15

TABLE 2: TRIAL PARTICIPANTS BY CLASS, AGE AND GENDER - WEEK 1 …………………………………………………… 15

TABLE 3: NUMBER OF TRIAL PARTICIPANTS ASSESSED BY WEEK …………………………………………………………… 15

TABLE 4: MEAN PLAQUE SCORES BY CLASS AND WEEK ………………………………………………………………………….. 16

TABLE 5: MEAN PLAQUE INDEX CLASSES 1B, 6B AND 9B COMBINED ……………………………………………………… 17

TABLE 6: DIFFERENCE IN MEAN PLAQUE INDEX BETWEEN WEEK 1 & 2 BY CLASS/BETWEEN CLASSES ……. 17

TABLE 7: DIFFERENCE IN MEAN PLAQUE INDEX BETWEEN WEEK 1 & 20 BY CLASS/BETWEEN CLASSES ….. 18

TABLE 8: DIFFERENCE IN MEAN PLAQUE INDEX BETWEEN WEEK 2 & 20 BY CLASS/BETWEEN CLASSES ….. 18

TABLE 9: MEAN PLAQUE INDEX OF CLASSES 1B, 6B 9B COMBINED BY GENDER …………………………………….. 19

TABLE 10: MEAN PLAQUE SCORES BY CLASS, GENDER, WEEKS, DIFFERENCE …………………………………………… 19

TABLE 11: NON-INTERVENTION GROUP – CLASS 1A ………………………………………………………………………………… 20

TABLE 12: PLAQUE SCORE – CLASS 1A …………………………………………………………………………………………………….. 20

TABLE 13: CLASS 1B WEEK 1 VERSUS CLASS 1A WEEK 20 ………………………………………………………………………… 21

TABLE 14: PLAQUE INDEX CATEGORIES BY GRADE AT WEEK 20 ………………………………………………………………. 21

TABLE 15: CHILDREN’S PERCEIVED HEALTH OF TEETH AND GUMS BY GRADE AT WEEKS 1 AND 20 …………. 22

TABLE 16: TOOTHACHE EXPERIENCE PRIOR TO TRIAL …………………………………………………………………………….. 23

TABLE 17: FREQUENCY OF TOOTHACHE SINCE BEGINNING OF YEAR TO WEEK ……………………………………….. 23

TABLE 18: FREQUENCY OF TOOTHACHE DURING TRIAL WEEK 1 TO 20 ……………………………………………………. 23

TABLE 19: RATING OF TRIAL TOOTHPASTE BY GRADE WEEK 2 ………………………………………………………………… 24

TABLE 20: RATING OF TRIAL TOOTHPASTE BY GRADE - WEEK 20 …………………………………………………………….. 24

TABLE 21: PREFERRED FLAVOUR BY GRADE - WEEK 20 ……………………………………………………………………………. 24

TABLE 22: RESPONDENTS BRUSHING REGULARLY AT HOME AND SCHOOL DURING TRIAL PERIOD ………….. 25

TABLE 23: FREQUENCY OF BRUSHING AT HOME DURING TRIAL PERIOD …………………………………………………. 25

TABLE 24: TOOTHPASTE SAMPLES FOR PARENTS/CARERS OF GRADE 1B CHILDREN ……………………………….. 25

TABLE 25: RATING OF TOOTHPASTE SAMPLES BY PARENTS/CARERS OF GRADE 1B CHILDREN ……………….. 25

TABLE 26: CHANGED BRUSHING HABITS OF PARENTS/CARERS DURING TRIAL PERIOD ………………………….. 26

TABLE 27: CHANGED BRUSHING HABITS OF SIBLINGS DURING TRIAL PERIOD …………………………………………. 26

TABLE 28: CHANGED BRUSHING HABITS OF OTHER FAMILY MEMBERS DURING TRIAL PERIOD ………………. 26

4

ABBREVIATIONS

DMFS/dmfs Index for decayed tooth surfaces (See below for explanation)

DMFT/dmft Index for decayed teeth (See below for explanation)

MOH Ministry of Health

MSM Medical Sailing Ministries

NOHS National Oral Health Survey

NOHP National Oral Health Policy

NRUC North Ringwood Uniting Church

OHP&PU Oral Health Promotion and Prevention Unit

PCV Presbyterian Church of Vanuatu

SDF Silver Diamine Fluoride (The term ‘Diammine’ is also used in the dental literature)

WFPHA World Federation of Public Health Associations

WHO The World Health Organization

TERMINOLOGY

Dental plaque

Definition: A biofilm or mass of bacteria that grows on surfaces within the mouth.

O’Leary plaque index

Measure for estimating status of oral hygiene by measuring dental plaque on tooth surfaces adjacent to

the gingival (=gum) margin. The simple O’leary index measures 6 zones, 3 on the vestibular (facing cheek

and lip) surfaces and 3 on the lingual (facing the tongue) surfaces of the teeth.

Plaque score = Total number tooth parts with Biofilm divided by six times the number of teeth present x

100 = % score

Caries Index

A dental caries index is used to illustrate how much of the dentition in an individual or population has

been affected by dental caries (=dental decay).

The DMFT (dmft) caries index is obtained by calculating the number of teeth present that have decay, the

number of teeth that have been extracted or lost due to decay, and the number that have been filled. A

more detailed index, DMFS (dmfs), records the status of all the surfaces of the teeth. Molars and

premolars have five surfaces, and front teeth have four surfaces.

Thus, the DMFT (dmft) and DMFS (dmfs) indices are composed of,

D = Decayed D = Decayed

M = Missing due to decay M = Missing due to decay

F = Filled due to decay F = Filled due to decay

T = Teeth S = Surfaces

The indices for permanent (adult) teeth are designated by letters in upper case (DMFT, DMFS) whereas

the primary (baby) teeth are designated by lower case letters (dmft, dmfs).

5

0

10

20

30

40

50

60

70

Class 1B Class 6B Class 9B Class 1A

Week 1

Week 2

Week 20

SUMMARY – Gudfala Tut Skul Projek

Introduction

A major causative factor in the two major oral diseases, dental caries (=dental decay) and periodontal

(=gum) disease, is poor oral hygiene, and the National Oral Health Survey Vanuatu 2017 revealed a high

percentage of the population did not comply with the recommendation of brushing teeth twice daily for

two minutes with fluoride toothpaste. For example, almost 40% of 5-7-year-olds reported “rarely” or

“never brushed” their teeth; moreover a high percentage (10.4%) of these children reported toothache

in the last month and 18.7% required urgent intervention based on current pain and/or infection of

dental origin recorded during the survey.1

Gudfala Tut Skul Projek, a supervised tooth brushing regimen using fluoride toothpaste based on coconut oil and calcium carbonate, was introduced to Vila Central School with the following objectives:

• To raise greater awareness of oral health in school children participating in a supervised tooth

brushing program

• To determine if a supervised tooth brushing program would lead to improvement in oral hygiene

habits in children attending a school in Port Vila, Vanuatu

• To ascertain if delivery of the program could be easily managed in a school setting in Vanuatu

• To develop and test acceptance of newly developed fluoride toothpaste suitable for production in

Vanuatu based on cold-pressed coconut oil which is readily available in Vanuatu

• To determine if the children participating in the program might influence the oral hygiene habits of

their respective family members (“Gudfala Tut Famli”)

All five objectives were achieved over the 20-week trial period and there was a sustained improvement

in oral hygiene (judged by reduction in mean plaque score) in the three intervention classes 1B, 6B and

9B. Furthermore, mean plaque score in class 1B (Intervention group) was significantly lower (p<0.001)

than Class 1A (Non-intervention group) at week 20.

The majority of the children (98.8%) readily adopted the new coconut oil-based toothpaste, judging it to

be ‘Gud tumas’ or ‘Gud’. There also appeared to be a reduction in toothache experience during the 20-

week trial period (17.9%) compared to a 20-week period (61.8%) prior to the trial.

Questionnaire responses revealed that the Gudfala Tut Skul led to improvement in oral habits of the

participants’ families thereby promoting “Gudfala Tut Famli”.

It was recommended that Gudfala Tut Skul be introduced initially to Kinder 1, Kinder 2 and Grade 1

Primary school children in Port Vila and Luganville and gradually phased out to cover all Kinder and

Primary School children throughout the archipelago.

Left: Bar graph representing mean plaque scores

by class (including class 1A) by weeks 1, 2 and 20.

Class 1A was not included in the trial but assessed

at Week 20 as a control.

There was no significant difference in mean plaque

score between class 1A at week 20 and that of

class 1B at week 1. However, mean plaque score in

class 1B (Intervention group) was significantly

lower (p<0.001) than Class 1A (Non-intervention

group) at week 20.

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1. INTRODUCTION

1.1. BACKGROUND AND RATIONALE

A general perception among dentists participating in the National Oral Health Survey (NOHS),

Vanuatu 20171 was a high prevalence of dental decay and gum disease in Vanuatu, particularly

with respect to dental decay in the two major urban centres, Port Vila and Luganville.

High levels of visible bacterial plaque and calculus accumulations frequently observed in survey

participants and a high prevalence of gingival (gum) bleeding on probing pointed to one of the

major causes of oral disease i.e., low compliance with respect to regular tooth brushing using

fluoride toothpaste in Ni-Vanuatu, including children attending schools in Port Vila.

It is a well-established fact that increased sugar consumption2 and poor oral hygiene3,

especially when combined with low exposure to fluoride ion, are the major aetiological factors

associated with dental decay. Low compliance with regular brushing is also a primary cause of

periodontal (gum) disease.3

It was therefore apparent, even before the data from the NOHS 2017 were analysed, that there

was an urgent need to educate children on the importance of daily tooth brushing with fluoride

toothpaste as well as diet modification, namely reduction in sugar consumption, in order to

reduce high caries prevalence and periodontal disease in future generations of children.

Perceived high caries and periodontal pocketing rates in Ni-Vanuatu have since been

substantiated following analysis of data gathered from the NOHS 2017 and now published in

the NOHS Report1, which was officially released to the Ministry of Health in November 2018.

National data for dental caries prevalence and experience (dmfs) in the 5-7-year-old group, for

example, were very high. Prevalence of dental caries in this age group was 69.9% and dental

caries experience 7.10 ± 8.24 (Mean ± SD). As expected, mean dental caries experience was

significantly higher in urban areas than in more isolated areas of the archipelago. The dmfs

index in the Urban Division was 10.92 ± 8.48 compared to 4.34 ± 6.95 in the Rural 2 Division.1

Furthermore, prevalence of gingival bleeding on probing in 5-7-year-olds was 77.5%, and the

number of bleeding sites 7.42 ± 6.6 (Mean ± SD). Almost 40% in this age group reported

“rarely” or “never brushed” their teeth. A high percentage (10.4%) of these children also

reported toothache in the last month and 18.7% required urgent intervention based on current

pain and/or infection of dental origin recorded during the survey.1

To instil life-long healthy habits it is essential to start early, ideally during the early formative

childhood years. Children also tend to respond more positively to incentives and on this basis

the concept of the Gudfala Tut Skul Projek was proposed.

Although the idea of supervised tooth brushing in schools is not new4-9, one of the pitfalls of

similar programs appears to have been lack of sustainability, mainly due to lack of supervision

and a supply of good quality tooth brushes and fluoride toothpaste on a continuing basis.

Based on the assumption that an improvement in oral hygiene using fluoride toothpaste would

lead to improvement in oral health and reduction in dental caries experience, the Gudfala Tut

Skul Projek had five main objectives:

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• To raise greater awareness of oral health in school children participating in a

supervised tooth brushing program

• To determine if a supervised tooth brushing program would lead to improvement in

oral hygiene habits in children attending a school in Port Vila, Vanuatu

• To ascertain if delivery of the program could be easily managed in a school setting in

Vanuatu

• To develop and test acceptance of newly developed fluoride toothpaste suitable for

production in Vanuatu based on cold-pressed coconut oil which is readily available in

Vanuatu

• To determine if the children participating in the program might influence the oral

hygiene habits of their respective family members (“Gudfala Tut Famli”)

1.2. TOOTHPASTE DEVELOPMENT

Introduction

A plan to manufacture toothpaste in Vanuatu made from natural local resources on a not-for-profit

basis was a key aspiration of the project. This would not only potentially offer local employment but

also provide a sustainable source of funding to cover the cost of providing free fluoride toothpaste

and tooth brushes to every child attending kindergartens and primary schools throughout Vanuatu.

Following presentation of the Gudfala Tut Skul concept to Dentalife Australia, a long-term supporter

of Medical Sailing Ministries (MSM), fluoride toothpaste composed of around 65% by weight of cold-

pressed virgin coconut oil and food grade calcium carbonate was developed in the company’s

research laboratory at no cost to MSM.

Coconut oil is readily available in Vanuatu and, being a natural preservative, offered a bonus with

respect to shelf-life of the product in a tropical environment. Claims that coconut oil is directly

beneficial to oral health, however, have not been substantiated by clinical research.

Hard corals, including Brain coral (Faviidae) and Elkhorn coral (acropora palmate) create

exoskeletons out of calcium carbonate (limestone). As a result of natural degradation and battering

from annual tropical storms dead coral can readily be found washed up along shorelines throughout

Vanuatu. Subject to chemical analysis and investigations to ensure its safety, this natural resource

could potentially be gathered to extract calcium carbonate for use in toothpaste production.

In the meantime Dentalife Australia formulated the trial toothpaste using cold-pressed coconut oil

manufactured in Vanuatu, food grade calcium carbonate and other natural products, including

emulsifiers, surfactants, thickeners, flavours and fluoride (Sodium fluoride) at the recommended

concentration of 1000ppm. The simple formula consisted of:

Coconut Oil 375g

Calcium Carbonate 335g

Propriety Mix 1 125g

Propriety Mix 2 250g

The formulation and instructions were simplified for mixing in small quantities using basic kitchen

equipment, including kitchen scales, hand-held food mixers and sausage fillers to transfer the mix

into the toothpaste dispensers described below.

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Flavours and colours

Children’s preferences for milder taste and bright colours influenced the choice of flavours. Three

flavour/colour combinations were developed; Bubble-gum/Pink, Tropical/Yellow and Mint/Blue. It

was assumed that the first two combinations would be more attractive to young children, while the

traditional mint flavour might be more attractive to older children and adults.

Dispensers

Two sizes of toothpaste dispensers were envisaged - a 500ml “sauce bottle” for use in the classroom

and 125ml version intended for a marketable, family-size supermarket product. Both bottle sizes

were made of low density polyethylene suitable for re-use, and also allowed gentle extrusion of the

toothpaste.

The sauce dispenser is ideal for extruding the paste onto the toothbrush without touching the

bristles, an important consideration with respect to prevention of cross-contamination in both the

classroom and home.

Furthermore, re-usable dispensers would reduce plastic waste, thereby supporting in principle the

Vanuatu Government’s policy banning non-biodegradable plastic to protect ocean life.10

Adjunctive project – tooth brush manufacture

For similar reasons the idea of local tooth brush manufacture has been pursued concurrently with

aspirations for local toothpaste manufacture. Growing awareness and concerns related to pollution

of the oceans with plastic products inspired a preference to manufacture tooth brushes made as

much as possible from natural bio-degradable materials.

Recently growing in popularity on the market are tooth brushes with handles made of bamboo,

which is a natural resource in Vanuatu. The idea of manufacturing tooth brushes with bamboo

handles in Vanuatu, however, is proceeding more cautiously as a number of manufacturers based in

the People's Republic of China already offer these products on the market. Careful business analysis

will be necessary to determine whether or not local production could compete with the mass market

production overseas.

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2. MATERIALS AND METHODS

2.1. Choice of School

Central School, Port Vila was an easy choice for the trial run of the proposed Gudfala Tut Skul Projek

for the following reasons:

• Close proximity to PCV Health and consequently the staff members responsible for mixing

the toothpaste and administering the maintenance phase of the trial

• Past and ongoing association with the school through the PCV Health school oral health

education program

• Progressive school leadership, school principal, staff and parent community

2.2. Selection of age groups

The selection of age groups, and therefore school grade classes, followed roughly the same age

groups as those used in the National Oral Health Survey i.e., 5-7-year-olds (Grade 1), 11-13-year-olds

(Grade 6) and 14-16-year-olds (Grade 9).

Different grades were also preferred because children at different ages might exhibit diverse

attitudes and behaviour towards participation in a supervised tooth brushing regimen in school.

2.3. Preliminary planning

Letters addressed to the Principal (Appendix 1) and parents (Appendix 2) of children in the respective

grades at Central School were sent to explain:

• The detrimental effects of poor oral hygiene and increased sugar consumption on oral health

• The desirability of promoting good oral health habits early in life

• The introduction of a newly developed toothpaste based on coconut oil and calcium

carbonate for trial in the school

• The details of the trial based on clinical examinations and interview questionnaires

• The importance of parental support and encouragement for the children participating in the

trial

• Benefits to the school community for participating in the trial

2.4. The dental team

The team comprised a volunteer dentist (Team leader) from Melbourne, Australia; three dentists and

two dental hygienists from Vila Central Hospital Dental Department; two oral health workers and two

eye care workers from PCV Health Eye and Dental Clinic; a volunteer mission worker from PCV; and a

paediatric nurse.

2.5. Materials – for recording plaque/questionnaires

• Class lists

• Forms for recording plaque accumulation following the O’Leary index (Appendix 3)

• Questionnaires (Bislama)

• Contrasting plaque disclosing gel (PlaqPro, Dentalife Australia)

• Rinse cups

• WHO CPI probes

• Mouth mirrors

• Compact digital camera with macro mode and flash (Panasonic DMC-TZ40)

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• Lip retractors

• IPA 70% (Clinicare, Dentalife Australia)

• Hand sanitiser (Handicare, Dentalife Australia)

• Hand mirrors

• Portable chairs and stools (for patient and examiner)

• Headlamps

• Tables and chairs (for recorders and questionnaire interviewers)

2.6. Materials –for classroom

• Tooth brush with child’s name on the handle

• Sealable plastic bag with respective child’s name

• A laminated A3 monthly calendar for recording supervised brushing at school (Appendix 4)

• Large stickers with the message, “Yu brasem tut evri taem” (Appendix 4)

• A 500ml bottle of toothpaste (either Bubble-gum, Mint or Tropical) for the classroom

• A 125ml bottle of toothpaste for the teacher’s personal use (members of family optional)

2.7. Materials –for home

• Sealable plastic bag with respective child’s name

• Tooth brush with child’s name on the handle

• “Rikod blong brasem tut blong mi” (Appendix 5)

• Sufficient tooth brushes for parents/guardians, siblings, other members of the family living

in the same household

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2.8. Training - dental team

The examiners, three dentists and one hygienist, were instructed in recording plaque using the

O’leary index. Two “rules” were imposed and stressed for recording dental plaque:

• Week 1 If there was any doubt with respect to the presence of plaque, the score

would be recorded as “0” (=No plaque)

• Weeks 2 & 20 If there was any doubt with respect to the presence of plaque, the score

would be recorded as “1” (=Plaque present)

Furthermore, the same examiners were assigned as much as possible to the same subjects for each

week throughout the trial. This was to reduce the risk of bias and inter-examiner variations in

recording.

The questionnaire interviewers were Ni-Vanuatu and proficient in the Bislama language. The

questionnaire interviewers were also trained to administer and supervise the application of

contrasting plaque disclosing gel.

Instructions were given in the use of a compact camera to take two photographs for each subject,

one of the teeth in occlusion with the lips retracted and one of the respective child’s names on the

examination chart for identification purposes.

12

2.9. Toothpaste manufacture

• Mixing bowl (2 to 4L)

• Electric food mixer with 2 beaters

• Large plastic spatula (cake mixing type)

• Small metal spatula

• Small beaker

• Large container (2 to 4L) to measure out the calcium carbonate

• A large scoop to dispense the calcium carbonate

• A kitchen scale to weigh out the ingredients

• Sausage maker for transferring the mixed paste into the toothpaste dispenser bottle

• Low density polyethylene bottles for toothpaste (500ml)

• Written instructions for mixing the toothpaste (Appendix 7)

13

Above: Oral health education

and instructions to the class;

dispensing toothpaste on the

first day of the trial.

Left: PlaqPro contrasting

plaque disclosing gel was

dispensed (Right) prior to

examination at each stage of

assessment.

2.10. Toothpaste ingredients

• Coconut Oil 375g

• Calcium Carbonate 335g

• Propriety Mix 1 125g

• Propriety Mix 2 250g

2.11. Instructions to children and class teachers

Verbal instructions were given to the children and teacher, emphasising its importance in

demonstrating the benefits of regular brushing with fluoride toothpaste (Appendix 8).

• Purpose of the school tooth brushing project

• Regular brushing at school – Gudfala tut skul

• Regular brushing at home – Gudfala tut famli

• Trial toothpaste with 3 different flavours

• The examination procedure + questionnaire Week 1

• The examination procedure + questionnaire Week 2

• The maintenance phase

• The examination procedure + questionnaire Week 20

• Written instructions given to teachers

• Teachers instructed on method of dispensing toothpaste without touching the

children’s brushes

• Spare tooth brushes left with teacher (1B, 6B) and class supervisor (9B)

• Laminated charts for each month and stickers for recording tooth brushing at school

14

2.12. Pre-examination procedure

• Prior to any tooth brushing at school

• 1-2 drops contrasting plaque disclosing gel placed on dorsum of tongue and lower

labial vestibule

• Child instructed to wipe the tongue as much as possible around the teeth for 1 minute

• Rinsed briefly with water

• Lip retractors placed and photograph of teeth taken

2.13. Examination

• Plaque scores recorded

• Individual oral health education using a hand mirror to point out plaque, particularly

in areas where child has long standing plaque as indicated by the contrasting plaque

stain

• Brushing technique

2.14. Post-examination

• Questionnaire (Weeks 1, 2 and 20)

• Observation of toothpaste dispensing (Week 1)

• Observation of class brushing under supervision (Week 1)

2.15. Maintenance phase

• Instructions for the maintenance phase and preparation of reports (Appendix 9)

• Regular reinforcement of oral hygiene

• Rotation of toothpaste flavours when replenishment undertaken

15

3. RESULTS

3.1. NUMBER OF TRIAL PARTICIPANTS

TOTAL CHILDREN BY CLASS - WEEK 1

Week Class Total number

in class

Trial participants Absent*

N % N %

1

1B 38 34 89.5 4 10.5

6B 37 33 89.2 4 10.8

9B 40 37 92.5 3 7.5

Total 115 104 90.4 11 9.6

Table 1. Total number of children by class and total trial participants (number and percentage of class) (*Excluded from trial i.e., were not clinically assessed, nevertheless participated in supervised tooth brushing)

TRIAL PARTICIPANTS BY CLASS, AGE AND GENDER - WEEK 1

Class and Age (years)

Trial participants

Male Female

N % N % 1B 34 17 50.0 17 50.0

5 1 1 - 0 - 6 20 9 45.0 11 55.0 7 12 6 50.0 6 50.0 Blank 1 1 - 0 -

6B 33 16 48.5 17 51.5

10 2 0 - 2 - 11 27 15 55.6 12 44.4 12 4 1 - 3 -

9B 37 20 54.1 17 45.9

13 1 0 - 1 - 14 27 13 48.1 14 51.9 15 7 5 71.4 2 28.6 16 1 1 - 0 - Blank 1 1 - 0 -

Total 104 53 51.0 51 49.0

Table 2. Total number and percentage of participants by class, age (years) and gender

NUMBER OF TRIAL PARTICIPANTS ASSESSED BY WEEK

Week 1 Week 2 Week 20 Class Assessed Assessed Absent Assessed Absent

1B 34 30 4 33 1 6B 33 33 0 25 8 9B 37 36 1 28 9

Total 104 99 5 86 18

Table 3. Number of participants assessed in weeks 1, 2 and 20

16

0

10

20

30

40

50

60

70

Class 1B Class 6B Class 9B

Week 1

Week 2

Week 20

3.2. PLAQUE SCORES

MEAN PLAQUE SCORES BY CLASS AND WEEK

Class Week

assessed N Mean

plaque score Standard

error Maximum

plaque score Minimum

plaque score

Week 1 34 46.85 4.23 100 0 1B Week 2 30 28.34 3.82 80 3 Week 20 33 17.72 2.09 48 1

Week 1 33 62.09 4.09 100 0 6B Week 2 33 27.57 3.14 90 0 Week 20 25 24.96 3.16 61 0

Week 1 37 34.27 3.58 94 1 9B Week 2 36 21.19 2.86 66 0 Week 20 28 17.96 2.37 55 2

Table 4. Mean plaque and standard error scores by class and by weeks 1, 2 and 20. Maximum and minimum plaque scores in each class.

DISTRIBUTION OF MEAN PLAQUE SCORES BY CLASS AND WEEK

Figure 1: Bar graph representing mean plaque scores by class and by weeks 1, 2 and 20.

17

MEAN PLAQUE INDEX CLASSES 1B, 6B AND 9B COMBINED

Pair Week N Mean Std. Error Mean

1 1 99 47.58 2.56

2 99 25.37 1.89

2 2 82 24.27 1.97

20 82 20.55 1.50

3 1 86 46.27 2.82

20 86 19.91 1.47

Table 5. Comparison of mean combined plaque index between weeks 1 and 2, 2 and 20, 1 and 20 1. There was a significant fall in mean plaque index from week 1 to week 2 (Pair 1), p<0.001 2. There was a further fall in mean plaque index between week 2 and 20 (Pair 2) but statistically

insignificant, p>0.05

DIFFERENCE IN MEAN PLAQUE INDEX BETWEEN WEEK 1 AND 2 BY CLASS

Class N Mean Standard Error

1B 30 21.60 4.08 6B 33 34.52 3.76 9B 36 11.42 2.21

DIFFERENCES IN MEAN PLAQUE INDICES WEEK 1 AND 2 BETWEEN CLASSES

Class Mean difference Standard Error Value of significance

1B 6B -12.92 4.86 0.03

9B 10.18 4.76 0.09

6B 1B 12.92 4.86 0.03

9B 23.10 4.64 0.00

9B 1B -10.18 4.76 0.09

6B -23.10 4.64 0.00

Table 6. Differences in plaque reduction week 1 and 2 between classes 1. There was a significant difference in plaque reduction between class 1B and 6B (higher), p<0.05 2. No statistically significant difference between class 1B and 9B 3. There was a significant difference between class 6B (higher) and 9B, p<0.001

Bebet hem i stap insaet long maot oltaem. Hem i save kakae

suga mo mekem asid. Sapos yu no brasem tut blong yu, bai i

gat plante bebet we i save mekem plante asid. Asid ia nao i

mekem tut blong yu i nogud.

18

DIFFERENCE IN MEAN PLAQUE INDEX BETWEEN WEEK 1 AND 20 BY CLASS

Class N Mean Standard Error

1B 33 28.76 3.62

6B 25 37.88 5.40

9B 28 13.25 3.53

Total 86 26.36 2.59

DIFFERENCES IN MEAN PLAQUE INDICES WEEK 1 AND 20 BETWEEN CLASSES

Class Mean difference Standard Error Value of significance

1B 6B -9.12 5.88 0.27

1B 9B 15.51 5.69 0.02

6B 9B 24.63 6.10 0.00

Table 7. Differences in plaque reduction week 1 and 20 by and between classes 1. There was a difference in reduction in plaque score of -9.12 between classes 1B and 6B (higher), but

not statistically significant 2. There was a difference in plaque reduction of 15.51 between class 1B (greater reduction) and 9B,

p<0.05 3. There was a difference in plaque reduction of 24.63 between class 6B (greater reduction) and 9B,

p<0.001

DIFFERENCE IN MEAN PLAQUE INDEX BETWEEN WEEK 2 AND 20 BY CLASS

Class N Mean Standard Error

1B 29 9.10 3.81

6B 25 0.44 3.06

9B 28 1.07 2.48

DIFFERENCES IN MEAN PLAQUE INDICES WEEK 2 AND 20 BETWEEN CLASSES

Class Mean difference Standard Error Value of significance

1B 6B 8.66 4.56 0.15

1B 9B 8.03 4.43 0.17

6B 9B -0.63 4.60 0.99

Table 8. Differences in plaque reduction week 2 and 20 between classes (There was no significant difference in the change in plaque score week 2-20 by or between any of the classes)

RABIS KAKAE emi ol kakae olsem bisket, kek, jam o hani, swit juing gam,

loli, jokolet, mo dring olsem lemonad, Coca Cola, o narafala jus we i gat

plante suga long hem. Ol bebet we oli stap insaed long maot oli laekem ol

rabis kakae ia tumas.

19

MEAN PLAQUE INDEX OF CLASSES 1B, 6B 9B COMBINED BY GENDER

Gender Week 1 Week 2 Week 20

Females 47.25 23.94 19.88

Males 47.17 26.78 19.93

Table 9. Mean plaque scores by gender

MEAN PLAQUE SCORES BY CLASS, GENDER, WEEKS, DIFFERENCE

Class Gender Week 1 Difference (Sig) Week 2 Difference (Sig) Week 3 Difference (Sig)

1B M 44.94 -3.82 (p=0.66)

26.93 -2.07 (p=0.72)

15.13 -5.05 (p=0.23)

F 48.76 29.00 20.18

6B M 62.56 0.92 (p=0.91)

29.68 4.09 (p=0.52)

27.15 4.57 (p=0.48)

F 61.64 25.58 22.58

9B M 36.75 5.40 (p=0.46)

24.21 6.38 (p=0.27)

18.94 2.48 (p=0.61)

F 31.35 17.82 16.45

Table 10. Difference in mean plaque scores by class and gender at weeks 1, 2 and 20. All insignificant.

TAEM – sapos yu no brasem tut tu o mo taem long wan dei mo

kakae tumas rabis kakae plante taem, ol tut blong yu bai i roten

hariap. I orait blong kakae rabis kakae samtaem nomo, olsem tu o

tri taem long wan wik be I nogud tumas blong kakae tu o mo taem

long wan dei.

20

PLAQUE INDEX BY GENDER

Figure 2: Mean plaque index by week and by gender

3.3. CLASS 1A (NON-INTERVENTION GROUP) PLAQUE SCORE – WEEK 20

NON-INTERVENTION GROUP – CLASS 1A

Class Total number

in class Number of participants Absent

n % n %

1A 37 25 67.6 12 32.4

Table11: Total number of children and trial participants by number and percentage of class 1A

PLAQUE SCORE – CLASS 1A

Class Week

assessed

No. of children assessed

Mean plaque score

Standard Error

Maximum plaque score

Minimum plaque score

Week 1 - - - - - 1A Week 2 - - - - -

Week 20 25 49.64 3.99 77 0

Table 12. Mean plaque and standard deviation scores class 1A at week 20; Maximum and minimum plaque scores (Note: Class 1A did not participate in the supervised tooth brushing trial)

21

CLASS 1B WEEK 1 VERSUS CLASS 1A WEEK 20

Class Mean difference Standard Error Value of significance 1B 1A -2.79 5.99 0.97

Table 13. Mean difference in plaque score between class 1B in week 1 and class 1A in Week 20 (Not statistically significant)

PLAQUE INDEX CATEGORIES BY GRADE AT WEEK 20

Class

Total number assessed

Plaque index 0-9 Plaque index 10-19 Plaque index ≥ 20

n % n n % n

1B 33 10 30 10 30 13 40 6B 25 4 16 6 24 15 60 9B 28 7 25 10 36 11 39 1A 25 1 4 1 4 23 92

Table 14. Number and percentage of students in plaque index categories at week 20

DISTRIBUTION OF MEAN PLAQUE SCORES BY CLASS AND WEEK

VERSUS CLASS 1A (NON-INTERVENTION)

Figure 3: Bar graph representing mean plaque scores by class (including 1A) by weeks 1, 2 and 20.

(Note: Class 1A was not included in the trial but assessed at Week 20 as a control. There was no

significant difference in mean plaque score between class 1A at week 20 and that of class 1B at week 1)

22

Photographs of teeth following application of contrasting plaque disclosing gel in Class 1A students

(Non-intervention group). Images 1, 2, and 3 are examples of children with poor plaque control. The

plaque stained pale blue colour in image #3 indicates very acidic plaque (<pH 4.5), which is more likely

to lead to demineralisation of tooth enamel. Image #4, on the other hand, represents an example of a

child with a relatively low plaque score compared to the rest of the class.

3.4. QUESTIONNAIRES

CHILDREN’S PERCEIVED HEALTH OF TEETH AND GUMS BY GRADE AT WEEKS 1 AND 20

Week Class Total No.

Very good Good Average Poor Very poor Don’t know

n % n % n % n % n % n %

1

1B 34 1 1 2.9 12 35.3 5 14.7 9 26.5 1 2.9 6 17.6

6B 33 1 3.0 6 18.2 15 45.5 2 6.1 0 0.0 9 27.3

9B 36 1 2.8 7 19.4 9 25.0 3 8.3 1 2.8 15 41.7

Total 103 3 2.9 25 24.3 29 28.2 14 13.6 2 1.9 30 29.1

20

1B 33 4 12.1 16 47.1 7 20.6 5 14.7 0 0.0 1 2.9

6B 24 4 12.1 6 18.2 12 36.4 0 0.0 0 0.0 2 6.1

9B 28 1 2.8 16 44.4 6 16.7 2 5.6 0 0.0 3 8.3

Total 85 9 8.7 38 36.9 25 24.3 7 6.8 0 0.0 6 5.8

Table 15. Children’s perception of their own oral health status.

1 2

3 4

23

TOOTHACHE EXPERIENCE PRIOR TO TRIAL

Week Class Total

respondents

Do you sometimes have toothache?

Yes No Don't Know

n % n % n %

1

1B 33 19 57.6 13 39.4 1 3.0

6B 33 23 69.7 10 30.3 - -

9B 36 21 58.3 15 41.7 - -

Total 102 63 61.8 38 37.2 1 1.0

Table 16. Responses to the question posed in Week 1, “Do you sometimes have toothache?”

FREQUENCY OF TOOTHACHE SINCE BEGINNING OF YEAR TO WEEK 1 (15 weeks)

Week Class Total

respondents

How many times have you had toothache since the beginning of 2018?

Once Twice 3 Times 4 Times Don’t Know

1

1B 9 1 4 - 3 1

6B 15 3 2 - 1 9

9B 20 5 4 1 1 9

Total 44 9 10 1 5 19

Percentage of Total 20.5% 22.7% 2.3% 11.4% 43.2%

Table 17. Frequency of toothache in children answering “Yes” to toothache since the beginning of the year

FREQUENCY OF TOOTHACHE DURING TRIAL WEEK 1 TO 20 (20 weeks)

Week Class Total

respondents

Did you experience toothache during the trial period?

Yes No Don't Know

n % n % n %

20

1B 32 8 25.0 24 75.0 - -

6B 25 3 12.5 22 87.5 - -

9B 27 4 14.8 23 85.2 - -

Total 84 15 17.9 69 82.1 - -

Table 18. Responses to the question at week 20, “Did you have any toothache during the trial period?”

Toothache is not only about the pain and discomfort. Toothache can have a

significant impact on quality of life leading to sleep disruption, diminished

capacity to concentrate during the day and absence from school. It can also

disrupt family life when young children suffering toothache wake their

parents or guardians and siblings during the night.

24

RATING OF TRIAL TOOTHPASTE BY GRADE WEEK 2

Week Class Total

respondents

Rating (n)

Very Good Good Didn't Like it

2

1B 25 6 19 -

6B 33 6 27 -

9B 30 2 25 3

Total 88 14 71 3

Percentage (%) 15.9 80.7 3.4

Table 19. Children’s rating of the trial toothpaste as a whole after 1 week

RATING OF TRIAL TOOTHPASTE BY GRADE - WEEK 20

Week Class Total

respondents

Rating (n)

Very Good Good Didn't Like it

20

1B 33 21 12 -

6B 25 9 16 -

9B 25 5 19 1

Total 83 35 47 1

Percentage (%) 42.2 56.6 1.2

Table 20. Children’s rating of the trial toothpaste assessed at the end of the 20-week trial period

PREFERRED FLAVOUR BY GRADE - WEEK 20 (Number and percentage)

Week Class Total respondents

All Bubble-gum Mint Tropical Did Not Use

n % n % n % n % n %

20

1B 33 - - 15 45.5 7 21.2 4 12.1 7 21.2

6B 25 - - 20 79.2 4 16.7 1 4.2 - -

9B 22 2 9.1 8 36.4 10 45.5 - - 2 9.1

Total 80 2 2.5 43 53.8 21 26.3 5 6.3 9 11.3

Table 21. Children’s preference for flavour assessed at the end of the 20-week trial period

• Brasem gud – yu brasem tut wetem tutpeist we i gat fluraed

long hem evritaem tu o mo taem long wan dei.

• Kakae gud – yu jusem helti kakae olsem lokal frut, pinat etc. Yu

no kakae tumas swit kakae plante taem.

• Dring gud – dring plante wota. Yu no dring lemonad, Coca Cola,

o nara jus we i gat plante suga long hem.

25

RESPONDENTS BRUSHING REGULARLY AT HOME AND SCHOOL DURING TRIAL PERIOD (Number and percentage)

Week Class Total respondents

Brushed at home and school during the trial period

Yes No

n % n %

20

1B 33 32 97.0 1 3

6B 25 23 92.0 2 8.0

9B 28 16 57.1 12 42.9

Total 86 71 82.6 15 17.4

Table 22. Respondents to question, “Did you brush your teeth regularly at home as well as at school since you started this trial?”

FREQUENCY OF BRUSHING AT HOME DURING TRIAL PERIOD (Number and percentage)

Week Class Number of

respondents

Frequency of brushing teeth at home during the trial

2-3 times per month

Once a month

2-3 times per week

Once a day Two or more times

a day

n % n % n % n % n %

20

1B 33 0 0.0 2 6.1 8 24.2 23 69.7 0 0.0

6B 23 1 4.4 1 4.4 6 26.1 15 65.2 0 0.0 9B 27 0 0.0 0 0.0 6 22.2 21 77.8 0 0.0

Total 83 1 1.2 3 3.6 20 24.1 59 71.1 0 0.0

Table 23. Respondents to question, “If ‘Yes’, how often have you been brushing your teeth at home?”

TOOTHPASTE SAMPLES FOR PARENTS/CARERS OF GRADE 1B CHILDREN

Class

Number of children given toothpaste samples for

parents/carers

“Did you give the sample toothpaste to your parents/carers?”

Yes No Don’t know

n % n % n %

1B 25 22 88 3 12 0 0

Table 24. Number of parents/carers (Grade 1B) given 20g tube samples of trial toothpaste (Mint flavour)

RATING OF TOOTHPASTE SAMPLES BY PARENTS/CARERS OF GRADE 1B CHILDREN

Class Number of parents/carers given toothpaste samples

Rating of toothpaste by parents/carers

Very good Good Didn’t like it

n % n % n %

1B 22 6 27.3 16 72.7 0 0

Table 25. Parent/carers’ rating of the trial toothpaste (Mint flavour)

26

+ + =

CHANGED BRUSHING HABITS OF PARENTS/CARERS DURING TRIAL PERIOD (n)

Week Class

Changed brushing habits (n)

Total respondents Yes No

20

1B 33 33 -

6B 24 24 -

9B 28 28 -

Total 85 85 -

Percentage - 100.0% -

Table 26. Response to question, “Did the school trial change the brushing habits of your parents/carers?”

CHANGED BRUSHING HABITS OF SIBLINGS DURING TRIAL PERIOD (n)

Week Class

Changed brushing habits (n)

Total respondents Yes No

20

1B 31 31 -

6B 24 23 1

9B 28 28 -

Total 83 82 1

Percentage - 98.8% 0.2%

Table 27. Response to question, “Did the school trial change the brushing habits of your siblings?”

CHANGED BRUSHING HABITS OF OTHER FAMILY MEMBERS DURING TRIAL PERIOD (n)

Week Class Total

respondents

Changed brushing habits (n)

Total answered this question Yes No Don't Know

20

1B 31 15 13 2 -

6B 23 6 6 - -

9B 28 15 14 - 1

Total 82 36 33 2 1

Percentage - - 91.7% 5.5% 2.8%

Table 28. Response to question, “Did the school trial change the brushing habits of any other family members living with you?”

27

4. SHORTCOMINGS OF DATA COLLECTION

4.3. Variations in examiners

Although the same examiners were assigned as much as possible to the same subjects throughout

the trial, one dentist had to leave halfway through a class in Week 2 due to a family illness and was

replaced by another dentist. Fortunately the latter had been assisting as a recorder and was familiar

with the procedure, and remained on the team as an examiner in Week 20.

4.4. Sample size

Constraints on finances and time limited the size of the original sample to three classes, one each

from grades 1, 6 and 9. Assuming all the enrolled students participated in the trial the maximum

sample size would be 114.

4.5. Attrition of trial participants

There were absent students on all the assessment days, mainly due to absence from school and

Grade 9B undertaking school tests in week 20.

Students absent in week 1 were excluded from the project; however they were still able to

participate in the supervised tooth brushing at school and were also issued with the home kits by

the teachers.

Some of the students assessed in week 1 were absent at either weeks 2 or 20 or both, but remained

part of the project. Consideration should be given to the possibility that attrition may have affected

the overall plaque scores.

4.6. Translation of questionnaires into Bislama

Difficulties were encountered with translation of the questionnaires from English into Bislama such

that compromises had to be made with phrasing questions and choices of answers. In retrospect it

would have been preferable if the interview questionnaires had been undertaken in English at least

in Grades 6 and 9 children at Vila Central School, where English was well understood and spoken by

students.

What do you think of this new toothpaste?

In between weeks 1 and 2 of the Gudfala Tut Skul Projek, adults in the market place were offered tooth

brushes and a sample of each flavour to try. A short questionnaire gauged general opinions on the

toothpaste including flavour preference. The overwhelming majority expressed acceptance of the product

and were pleased about the possibility of production in Vanuatu. Most adults preferred the mint flavour.

28

Figure 4. The above images were taken of plaque-stained teeth from a 6 year-old child (Student code

103, Appendix 9) in Class 1B at Week 1, Week 2, and Week 20.

Week 1: Showing heavily stained plaque (Score = 95); the deep red and purple stain is indicative of old

plaque and deficient attention to regular tooth brushing.

Week 2: Reveals a significant reduction in plaque score (68), and the stain is a pale pink colour, indicative of

immature plaque only.

Week 20: By week 20 the score had reduced to 11 and there is no visibly stained plaque. By developing a

sustained daily tooth brushing regimen, this child has substantially reduced the risk of dental decay in her

existing mixed dentition and the majority of permanent teeth due to erupt over the period she will attend

primary school.

5. DISCUSSION

5.1. Plaque scores

All three grades showed significant reductions in mean plaque scores between weeks 1 and 20 i.e.,

over the duration of the project (Table 4 and Figure 1). The major reduction in plaque scores were

made during the first week; there was no significant difference in plaque scores between weeks 2

and 20 for any of the classes individually or combined (Table 5).

The series of photographs in Figure 4 is an example of the improvement in oral hygiene that can be

achieved in an individual through a simple regimen of group brushing at school.

Class 6B had the highest initial mean plaque score at week 1, significantly higher than Class 1B

(p<0.05) and 9B (p<0.001), as well as the largest reduction in mean plaque score after the first week

of the trial (Table 6). The teenage group in Class 9B, on the other hand, started from a lower mean

plaque score, possibly reflecting a greater motivation for improving their appearance and self-image

at a sensitive stage of their social development. There was no significant difference, however, in

initial mean plaque scores between Class 9B and Class 1B.

The difference in reduction in mean plaque index between classes 1B and 6B over the period of the

trial (Weeks 1-20) was not statistically significant. On the other hand there was a significant

difference in mean plaque reduction of 15.51 between class 1B (greater reduction) and 9B (p<0.05);

a significant difference in mean plaque reduction of 24.63 between class 6B (greater reduction) and

9B (p<0.001, Table 7).

Although there was no statistically significant difference in mean plaque reduction between weeks 2

and 20 (Table 8), it nevertheless provided evidence that the improvement in oral hygiene was

sustained over the 20-week trial period.

Week 1 Week 2 Week 20

29

The incentive for maintaining the reduction in plaque scores, however, appeared to be different for

the junior classes (1B & 6B) compared to the teenage group (Class 9B).

The latter cohort was disinclined to participate in tooth brushing at school as they thought it was an

exercise more suitable for the younger children. They appeared to be more engaged, however,

during individual oral hygiene instruction sessions at each stage of assessment in weeks 1, 2 and 20.

Hand mirrors and probes were used to point out areas where heavily stained plaque was present,

and teenagers were more attentive to personal demonstrations of brushing technique. Presumably

this cohort improved brushing at home thereby achieving and maintaining a reduction in mean

plaque score throughout the 20-week trial period.

On the other hand, the younger children, especially in Class 1B, appeared to delight in the daily

routine of brushing their teeth together as a group. The Class 1B teacher confessed that the children

invariably reminded her on the few occasions when she forgot the class brushing session prior to

commencement of the daily learning activities.

Although not statistically significant Class 1B sustained the largest reduction in mean plaque score

between weeks 2 and 20 (Table 8). Moreover, the children in Class 1B were delighted to be informed

that their mean plaque index was officially declared the lowest and therefore the best of the three

classes at the conclusion of the trial (Week 20).

With respect to gender, males in Class 1B tended to have lower plaque scores than females; females

in Classes 6B and 9B, on the other hand, tended to have lower scores than males. None of the

differences, however, were statistically significant (Tables 9 & 10, Figure 2).

Fortuitously, the project planning team was unaware that there were two streams of classes in each

grade and had only prepared for a maximum of 40 children in each grade. This oversight provided

the opportunity at the end of the project to examine and compare Class 1B (=Intervention group)

with Class 1A (=Non-intervention group).

It was pleasing to note from the point of view of comparison that the mean plaque score (49.64,

Table 12) for Class 1A was similar to that of Class 1B (46.85, Table 4) prior to commencement of the

supervised tooth brushing program, and there was no statistical difference between the two (Table

13). The bar graph in Figure 3 reveals the stark contrast between the three intervention classes at

Week 20 and the non-intervention class 1A. Mean plaque score in class 1B (Intervention group) was

significantly lower (p<0.001) than Class 1A (Non-intervention group) at week 20.

Table 14, showing the numbers of individual students within three ranges of plaque score (0-9; 10-

19; ≥20) at week 20, also provides some interesting comparisons. Students in class 1B in the 0-9 or

low plaque score range represented 30% of the class compared to only 4% in class 1A. Similarly, in

the moderately low 10-19 plaque score range the representation was 1A = 30% and 1B = 4%. The

percentage of students with a plaque score of ≥20 in the non-intervention group (1A = 92%) was

more than double that of the intervention group (1B = 40%).

5.2. Questionnaires

Children’s perceived health of teeth and gums

Limited time and resources could not justify a full statistical analysis of questionnaires.

Consequently a qualitative analysis was undertaken and this should be taken into consideration

when interpreting the findings.

30

Perception of children’s own oral health status (Table 15) was interesting. Children as a whole

perceived an improvement in the health of their teeth and gums over the duration of the trial.

Of particular interest, however, was the overall response from teenagers (Class 9B). The

combined ‘Very good’ and ‘Good’ responses at week 1 was 22.2% compared to 47.2% at week 20

i.e., a 113% increase in ‘very good’ and ‘Good’ responses over the trial period.

Similarly Class 1B children also perceived an improvement in the health of their teeth and gums

with combined ‘Very good’ and ‘Good’ responses of 38.2% at week 1 compared to 59.2% at week

20 i.e., an increase of 55%.

At the other end of the spectrum the class 1B responses, ‘Very poor’ and ‘Poor’, had reduced

from 29.4% in week 1 to 14.7% in week 20 i.e., a difference of 14.7% or a 50% reduction.

A pertinent question might have been, “Why do you perceive an improvement in the health of

your teeth and gums?” In the absence of the latter one can only speculate that students might

have perceived improved “feeling of cleanliness or freshness”, or possibly reduction in pain and

discomfort or reduced bleeding from the gums as criteria for judging improvement in oral health

status.

Toothache experience

Responding to the question, “Do you sometimes have toothache?” 61.8% of children in week 1

answered, ‘Yes’ (Table 16).

This is higher than the National average (36.2%) in relation to past history of toothache, as might

be expected given that caries prevalence and experience is higher in urban areas1 than elsewhere

in the archipelago.

Students in class 6B tended to report higher prevalence (69.7%) than classes 1B and 9B students

(57.6% and 58.3% respectively). This may not have been statistically different, nevertheless

higher prevalence of toothache might be expected in this group because lesions in the late mixed

dentition would have continued to progress. Furthermore, there would have been a higher

number of mobile deciduous teeth close to exfoliation, and “wobbly” teeth are often

uncomfortable.

The beginning of the year 2018 was used as a reference (approximately 20 weeks duration) to

assist children in recalling frequency of toothache. Of the 44 respondents 20.5% reported

toothache on at least one occasion while 36.4% reported two or more episodes. A high

percentage (43.2%) responded, “Don’t know” (Table 17).

A question related to history of toothache was posed to all children at the end of the trial period

(20 weeks duration), “Did you have any toothache during the trial period?” Of the 84

respondents 17.9% answered, ‘Yes’ and 82.1% ‘No’ (Table 18). This is a substantial reduction in

‘Yes’ responses compared to week 1 (61.8%). Such a large reduction could be explained as a

result of a significant reduction in acidinogenic/cariogenic bacteria in the mouth due to reduction

in plaque scores.

Rating of trial toothpaste

Acceptance appeared to improve throughout the trial period as children adapted to the different

textures and flavours of the coconut-based product. The combined ‘Gud tumas’ and ‘Gud’

31

responses stayed much the same at weeks 2 and 20, but the proportion of ‘very good’ responses

had increased from 15.9% in week 2 to 42.2% by week 20. The largest shift in acceptance,

however, was in class 1B students.

It should be noted at the week-2 assessment that each class had only experienced one flavour

namely, 1B – Bubblegum, 6B – Mint and 9B – Tropical.

By week 20 the majority of children overall (53.8%) preferred the Bubblegum flavour and the

least popular flavour was Tropical (6.3%). Bubblegum was by far the most popular in class 6B

students (79.2%). A modest percentage (11.3%), mainly from class 9B, did not use the trial

toothpaste at all; the fact that students in class 9B were allocated the least popular flavour

(Tropical) in the first week of the trial may have influenced their decision not to partake in

brushing at school.

Brushing frequency

In answer to the question, “Did you brush your teeth regularly at home as well as at school since

you started this trial?” 82.6% (N=86) responded, ‘Yes’ (Table 22).

However, the number (N=83) answering the related question, “If ‘Yes’, how often have you been

brushing your teeth at home?” (Table 23) indicates that nearly all the respondents answered this

question even if they were not brushing regularly at home. This must be taken into account

when judging the responses; nevertheless 71.1% indicated that they were brushing at home once

a day as well as at school. This is more than double the national average of 33.3% for the same

combined age groups.1

It is also interesting to compare classes 1B and 6B with their respective age groups in the national

survey. Assuming that classes 1B and 6B children were brushing at school, 69.7% of class 1B

students brushed their teeth ≥2 times a day compared to the national average at only 21.3%;

65.2% of class 6B students brushed ≥2 times a day compared to 35.2% nationally.1

Toothpaste samples for class 1B parents

Samples of mint-flavoured trial toothpaste were offered to class 1B students for parents to try at

home and rate the toothpaste ‘very good’, ‘Good’ or ‘Didn’t like it’.

Of the 25 parents, 22 responded (Table 24), and all the responses were positive with 27.3% rating

the product as ‘very good’ and 72.7 rating it ‘Good’ (Table 25).

Changing family oral health habits

At the end of the trial, students were also asked if the trial had influenced brushing habits of

parents/carers; siblings; and any other family members living in the child’s home.

Factors that could have potentially influenced other family members’ brushing habits included:

the child’s home brushing record booklet; provision of sufficient tooth brushes to all members of

the family living at home with the child; observing changed positive habits of the child in relation

to regular brushing at home.

When asking the question, “Did the school trial change the brushing habits of your

parents/carers?” questionnaire interviewers ascertained if this was in a positive or negative way.

32

At week 20, 100% (N=85) believed that the trial had positively influenced the brushing habits of

parents/carers (Table 26). Similarly 98.8% (N=83) indicated that the brushing habits of siblings

had been changed in a positive way (Table 27); and finally, 91.7% of respondents (N=36) believed

that other family members had also positively changed their brushing habits (Table 28). The

smaller number of respondents, of course, was related to the fact that not all families had “other

(extended) family” members living in the same household.

Therefore, there is evidence here to suggest that the concept of “Gudfala Tut Famli” under the

influence of the children themselves might be an added bonus of the Gudfala Tut Skul Projek.

5.3. The case for supervised tooth brushing with fluoride toothpaste in schools

In 2013 the World Federation of Public Health Associations (WFPHA) General Assembly passed the

following statement:11

Every child has a right to good oral health. Oral health problems in children can impact on many

aspects of their general health and development, causing substantial pain and disruption to

their lives and often altering their behaviour. Oral health is an integral part of overall well-being

and essential for eating, growth, speech, social development, learning capacity and quality of

life.

To promote oral health every child should have access to:

• Oral health education including oral hygiene instructions and dietary advice, and access to

affordable toothbrushes and toothpaste containing fluoride as soon as the first primary tooth

erupts

Gudfala Tut Famli! – A healthy tooth family from Class 1B, 2018

(Permission to use image sought and granted, March 07 2019)

33

• Preventive interventions, appropriate to the infrastructure and priorities of the country, which

may include dental sealants, community fluoridation, and regular fluoride varnish application.

• Treatment of early stage decay to stop it from progressing to cavities, and treatment of dental

cavities, acute pain and other oral diseases.

• Environments that eliminate advertising of unhealthy foods to children.

Through good oral health all children will have an equal opportunity to thrive and reach their

full potential for a promising future.

The first point in the above statement is highly relevant with respect to the case for rolling out

Gudfala Tut Skul Projek. The effectiveness of brushing teeth for two minutes twice daily with

fluoride toothpaste in reducing dental caries has been well documented,12,13,14 and a supervised

brushing program at school would lead to substantial cost reduction in oral health services, not to

mention reduction in the cost of pain and suffering, loss of concentration in class and absence

from school.

A study undertaken in 2015 compared the cost of providing the Scotland-wide nursery tooth

brushing program with associated National Health Service (NHS) cost savings from improvements

in the dental health of 5-year-old children: through avoided dental extractions, fillings and

potential treatments for decay. The NHS costs associated with the dental treatments for five-year-

old children decreased over time. In the eighth year of the tooth brushing program the expected

savings were more than two and a half times the costs of the program implementation.15

Furthermore, biannual fluoride varnish application (second point in WFPHA statement above) has

been shown to reduce caries by 37% in primary dentition and by 43% in permanent dentition.16

Cost per child for two applications per year would be less than VT200 and could be funded by

imposing a modest VT200 levy for each child attending Kindergarten and Grade 1 primary School.

Supervised brushing with fluoride toothpaste and applications of fluoride varnish are at the core of

the Childsmile Programme in Scotland.4,5 The Childsmile Programme has been adapted to several

other countries and in March 2018 was invited to produce the material for the WHO Collaborating

Centre in Malmo.17 An example of adaptation to other countries is the “MY SMILE” program, Dubai

UAE.18

Gudfala Tut Skul Projek has successfully sought and been given permission to adapt the Childsmile

Manual for use in Vanuatu (Appendix 12).

As Gudfala Tut Skul Projek becomes established it would also open up opportunities for treatment

of early stage decay (third point in WFPHA statement above) using risk assessment, fluoride

varnish and silver diamine fluoride (SDF). This is known as secondary prevention of dental decay.

Indeed, introduction of Gudfala Tut Skul should be a pre-requisite for SDF programs as the latter

has been shown to be far less effective in children who do not regularly brush with fluoride

toothpaste.

34

6. RECOMMENDATIONS

The following recommendations are based on:

• Findings of the Gudfala Tut Skul Projek trial at Central School in 2018

• The experience of similar programs in other countries e.g., Childsmile, Scotland

• The premise that the earlier children start regularly brushing teeth with fluoride toothpaste

the greater impact it will have on reduction of dental caries

6.1. All pre-school and primary school age children should have access to:

• Free tooth brush and toothpaste

• Participation in a supervised tooth brushing program at Kinder/Primary School

• Participation in biannual applications of fluoride varnish (where applicable according to risk-

assessment)

6.2. Phased roll-out of Gudfala Tut Skul:

PROPOSED TIMETABLE FOR PHASED ROLLOUT OF GUDFALA TUT SKUL - VANAUTU

Year Stage

2019

Adaptation of the “Childsmile - Nursery and School toothbrushing programme” manual to suit needs and culture in Vanuatu

Plan initially for Kinder 1, Kinder 2 and Primary Grade 1 children in main Urban centres, Port Vila and Luganville, where caries prevalence and experience is generally higher than Rural 1 and Rural 2

Minimum of 5 schools (Kinder 1, Kinder 2 and Primary Grade 1 children), 4 in Port Vila and 1 in Luganville commencing July

2020 Minimum of 30 schools (Kinder 1, Kinder 2 and Primary Grade 1 children), Port Vila and Luganville

2021 All schools (Kinder 1, Kinder 2 and Primary Grade 1 children) in Port Vila and Luganville

2022 First assessment of program: Caries experience survey of Grade 1 children, who commenced the program in Kinder 1 2019 (Compare with NOHS 2017) (i.e., after 2 years in the program = 5 schools)

2022 - 2024 Expansion into Rural 1 areas (Kinder 1, Kinder 2 and Primary Grade 1 children)

2025 - Further expansion to cover the whole country - Urban, Rural 1 and Rural 2 (Kinder 1, Kinder 2 and Primary Grade 1 children)

2026 Second assessment of program: Caries experience survey of Grade 6 children, who commenced the program in Kinder 1 2019 (Compare with NOHS 2017 and First assessment 2022)

2026 - Further expansion to cover all children from Kinder 1 up to Grade 6 Primary School children

7. CONCLUSIONS

Gudfala Tut Skul Projek introduced as a trial at Vila Central School demonstrated that a supervised

tooth brushing program is effective in reducing dental plaque score in children. Furthermore, the

reduction was sustained over the trial period of 20 weeks.

A new, fluoride toothpaste based on cold-pressed coconut oil and calcium carbonate was readily

accepted by children and adults.

It is recommended that Gudfala Tut Skul be introduced to all Kinder and Primary Schools in Vanuatu

commencing in the two major urban centres, Port Vila and Luganville. A timetable for a phased

rollout of Gudfala Tut Skul was proposed to reduce the cost impact.

35

APPENDIX 1 – LETTER TO PRINCIPAL VILA CENTRAL SCHOOL

36

37

APPENDIX 2 – LETTER TO PARENTS/CARERS VILA CENTRAL SCHOOL

38

39

APPENDIX 3 – PLAQUE SCORE RECORD CHART

40

APPENDIX 4 – CLASS TOOTH BRUSHING RECORD AT SCHOOL (A3 LAMINATED)

41

APPENDIX 5 – HOME TOOTH BRUSHING RECORD BOOKLET

42

43

TOOTHPASTE MIXING INSTRUCTIONS

Equipment:

1. A 3 Litre Mixing Bowl (2 to 4L required)

2. Note: Glass is best as the Mixer Beaters cannot damage it.

3. The Electric Mixer with 2 Cake Mixer Beaters

4. Large Plastic Spatula (cake mixing type)

5. Small Metal Spatula (or knife is OK)

6. Small Beaker (or cup is ok)

7. Large Container (2 to 4L) to measure out the Calcium Carbonate

8. A large Scoop to dispense the Calcium Carbonate

9. A Scale to weigh out the ingredients

10. Sausage maker for transferring the mixed paste into the toothpaste dispenser bottle

11. Low density polyethylene bottles for toothpaste (500ml)

Procedure for Making Coconut Oil Toothpaste:

Step 1: Making the Paste (1000g)

1. Coconut Oil (CNO) 375g

2. Flavour Mix (FM) 125g

3. Calcium Carbonate (CC) 335g

4. Colour Mix (CM) 250g

Note: Make sure the Coconut Oil (CNO) is in the liquid form not the paste. If in paste form, you will

need to warm it up. Either warm for 30 minutes at 40oC or warm in the microwave for 1-2 minutes.

(Warning: Watch the oil in the microwave to make sure the CNO is not overheated. Heating above

40oC will damage the CNO)

5. Weigh the CNO into the mixing bowl

6. Weigh Calcium Carbonate (CC) into a separate container

7. Weigh out the Flavour Mix (FM) and add selected Flavour to the CNO

Note: Shake the Flavour Mix bottle well before dispensing.

8. Mix with Electric Mixer till blended and liquid is homogeneous.

9. Next, use a scoop or similar to add the Calcium Carbonate (CC) to the bowl containing the CNO &

Flavour Mix. At this stage, use the Plastic Spatula to hand mix the CC into the CNO. Add the CC in 3

lots to the CNO, hand mixing each time to cover the CC with the CNO. Clean off the Spatula with

the Knife each addition.

Note: The mix will be quite lumpy, at this stage, but don’t worry.

APPENDIX 6 – INSTRUCTIONS FOR MIX TOOTHPASTE

44

10. Now use the Electric Mixer to mix the paste. Use on slow speed at first to thoroughly mix the CC

into the CNO/Flavour Mix. Rotate the bowl and move the Mixer Beaters around to incorporate all

the CC powder.

11. Continue mixing with the Electric Mixer and increase the speed of the mixer to help homogenise

the paste. You can use the Boost Button on and off to help mix and break up lumps. This mixing

will take 10 to 20 minutes to achieve a smooth consistent mix that has the consistency of

“thickened cream” (not whipped cream at this stage).

12. You can use your Plastic Spatula to push and mix paste stuck to the sides of the bowl and help get

a uniform mix. You can also check the mix with the spatula. Clean off the spatula using the Knife

each time. Once you have achieved the “thickened cream” consistency, go onto the next step.

13. Next, weigh out the Colour Mix (CM) matching up with Flavour Mix into a separate beaker (or cup).

Restart the Electric Mixer on the slowest speed and have a 2nd person help add the CM. Add

approximately 1/3 at a time and mix until the liquid is absorbed. Once absorbed, added another

1/3. Continue till all the liquid is added.

Note: The mix will start to thicken.

You must now mix to incorporate the Mix evenly through the paste. You can again use the Spatula

to assist incorporating the cream around the sides of the bowl.

14. Mix until a uniform colour is achieved. Check through the mix with the spatula to see there is no

white cream remaining, particularly at the bottom of the bowl.

15. Once a uniform colour is achieved and the mix has a consistency of “thick whipped cream” you can

stop mixing and prepare for filling the Toothpaste!

Step 2: Filling the Paste

1. Assemble the Sausage Maker (SM) without the “Winder” so you can back fill with paste.

2. Place a cap on the end of the nozzle.

3. Use a large spoon to fill the SM and then connect the winder to start filling your bottles.

4. Fill your Toothpaste Bottles with the paste and then immediately cap the bottles with your

dispensing caps.

5. You are now ready to start using your Toothpaste.

6. If you do not have a SM then use you Small Spatula or Knife to hand fill the bottles.

Step 3: Clean up

1. Clean up all utensils and equipment immediately after you’ve finished filling.

45

GUDFALA TUT SKUL PROJEK

Central School, Port Vila, April–July 2018

Instructions to students/teachers

Explain the purpose of the school tooth brushing project.

1. The NOHS found that many people neglect one of the most important ways of preventing tooth decay i.e.,

brushing their teeth for two minutes twice each day using toothpaste that contains fluoride.

There are several reasons for this, but it is important to make tooth brushing a regular habit while young,

because it is very difficult to adopt new habits as an older person.

2. (Explain “fluoride” depending on age of the students) – Basically “fluoride” helps to fight dental decay.

3. Because oral health affects our lives in so many different ways, including our general health, the “Gudfala

Tut Skul Projek” will be introduced to Central School as a trial project to see if it improves tooth brushing

habits and oral health in school children.

4. We would also like to see if the school project has any effect on your families’ oral health. In fact we would

like to call this a “Gudfala Tut Famli ProjeK” because you could be the oral health teachers for your

families!

How will we do this at school?

1. You will be given a tooth brush with your name on the handle and a small plastic bag to store the brush

after use in the classroom.

2. Every morning at school your teachers will instruct you to brush your teeth before commencing your

lessons.

3. You need to place only a small amount of tooth paste, not much bigger than a large peanut, on your brush.

4. Brush all the surfaces of your teeth on the inside, outside and biting surfaces.

5. If you have not been brushing your teeth regularly, you might find that your gums bleed. Do not worry

about this, and do not let this stop you from brushing. After brushing regularly twice each day, you will find

that the bleeding will become less and less until it stops altogether.

6. Spit out the toothpaste after brushing. You do not have to rinse your mouth, because the fluoride helps to

strengthen your teeth against decay. But if you prefer to rinse with water, then that is okay too.

7. Every time the class cleans their teeth together the teacher will place a sticker on the chart in the class

room. “Yu brasem tut evri taem,” is written on the sticker.

8. At the end of each month the chart will be collected by the supervisors and the class will receive a new

chart for the next month.

9. There will be three flavours of toothpaste. Each time the toothpaste bottle is refilled by the supervisors,

the flavour will be changed so that you can decide at the end of the project which flavour you like best.

Maybe you will like one flavour much more than the other two, or you might like all three equally.

10. If you lose or damage your tooth brush, just let your teacher know and they will provide you with a

replacement.

How will we do this at home?

1. Everyone will have a “Gudfala Tut” bag to take home.

2. The bag will contain,

a. A tooth brush to use at home.

b. Extra tooth brushes for your parents/guardians and any other members of your family currently

living with you.

c. A home tooth brushing record book, which has a letter to your parents/guardians.

d. Some stickers - stars for Grades 1 and 6, and spots for Grade 9.

e. A small sample of tooth paste for your parents/guardians of Grades 1 and 6 to try at home.

APPENDIX 7 – INSTRUCTIONS TO STUDENTS AND TEACHERS

46

f. At the end of the project you will be asked to bring your record book to school and exchange it for

a small gift, even if you have not brushed your teeth at home!

But, if you haven’t brushed your teeth regularly, we will all be very sad!

But, before we start – Week 1 (Today)

1. Some helpers will ask you some questions about your teeth, including how often you brush your teeth.

Because the information is used for research, it is very important that you give honest answers – we will

not tell anyone else about your personal information.

2. A dentist will check your teeth to see how well you have been brushing your teeth.

3. To do this the dentist will place 2-3 drops of a harmless dye on your tongue. You wipe this all around your

mouth with your tongue for one minute and then rinse with water.

4. The dye will show colours of purple, red or blue wherever there are bacteria on your teeth.

5. This helps the dentist count areas where the bacteria are stuck to surfaces of your teeth.

6. The dentist will also use a small instrument called a dental probe that will gently touch your gums to see if

they bleed. The dentist will count how many places in the gum that bleed easily when touched.

It is not a “stik” so don’t be afraid.

7. When everyone in the class has been checked by a dentist, one of the supervisors will show the class how

to brush teeth correctly, and then everyone will brush their teeth together.

8. Even your teacher will be given a brush and their own sample of toothpaste to try at school or at home.

Week 2

1. The supervisors will ask you some questions about what you think about the toothpaste and any changes

in your tooth brushing habits. Don’t forget it is very important to give honest answers.

2. The dentist will check your teeth again, but will only use the dye this time to check how well you have been

brushing your teeth during the first week. The dentist will not be checking to see if the gums bleed this

time.

3. At the end of the second week, the supervisors will collect the first class tooth brushing record for the

month of April.

4. The supervisors will also check how much toothpaste is left in the bottle and replace it when nearly empty

with a different flavour.

After the holidays and the following three months

1. The supervisors will visit the school each week to check on your progress, answer any questions and

replace the toothpaste bottles when nearly empty.

2. If you have any problems, or you lose or damage your tooth brush, then let the teacher know straight

away.

3. The project will continue for 3-4 months.

4. At the end of the project, the dentists will make one more visit to check your teeth using the coloured dye

and will also check your gums again for any signs of bleeding.

5. At the end of the project the organisers will give a donation to Central School and a sign announcing that

your school is a “Gudfala Tut Skul”

The results of this project will be given to government representatives to help decide if it is a good idea to introduce

tooth brushing in all schools in Vanuatu.

So all of you at Central School could be responsible for making a big change to the oral health of all the people in

Vanuatu!

Thank you very much to your school principal, your teachers, your parents/guardians, your families and most of all

to you for helping with this project!

47

Gudfala Tut Skul Projek – Instructions and Reports

Friday, April 27 (Last day of school holidays.

1. Collect the classroom tooth brushing records (April) and any remaining stickers.

2. Remind the children to keep up their home tooth brushing twice each day for 2 minutes each

time. Remember to brush the teeth systematically so that they brush every tooth.

3. Collect the 500ml (large) toothpaste containers.

4. Inform teachers that they can continue using their toothpaste samples, but please return them

after the holidays

Monday, May 14 (First day of school after holidays)

1. Deliver the new classroom tooth brushing records (May) and the required number of stickers to

cover the school days only for the month of May (Count the number of white squares on the

chart)

Then every Friday (except during school holidays) go to school and check toothpaste. Replace when

necessary.

1. Attend Central School when school starts and check children brushing their teeth

2. Re-inforce oral hygiene habits and correct technique

3. Check toothpaste dispensers to ensure cleanliness, and look for any sign of discolouration in the

toothpaste

4. Check amount of toothpaste remaining in dispensers and replace dispensers when necessary

1. Rotate the flavours each time you replace the 500ml dispenser for the class

For example, on the first change, Grade 1 = Flavour #3; Grade 6 = Flavour #1; Grade 9 = Flavour

#2

2. Check and replace any toothbrushes where necessary making sure the child’s name is written on

the handle

Collect the toothpaste dispensers on the last day of term 2, and have a fresh batch ready for delivery

on the first day back at school in Term 3.

End of each month, commencing May 31

1. Collect monthly class tooth brushing record chart

2. Send progress report to Barry end of May and June

Date Activity

APPENDIX 8 – INSTRUCTIONS FOR MONITORING PROJECT

48

INDIVIDUAL PLAQUE SCORES BY WEEK - CLASS 1B

Student Code Gender

Plaque scores

Week 1 Week 2 Week 20

101 M 59 17 Absent 102 F 38 47 25 103 F 95 68 11 104 M 10 10 9 105 M 54 32 13 106 F 67 57 35 107 M 53 18 24 108 M 51 20 10 109 F 70 13 43 110 F 100 80 48 111 F 0 3 5 112 F 39 29 16 113 M 11 Absent 6 114 F 86 11 7 115 F 44 13 11 116 F 33 12 37 117 F 33 29 12 118 F 12 Absent 1 119 M Absent Absent Excluded 120 M 74 69 29 121 F 21 7 9 122 M 72 25 29 123 M 31 14 4 124 M 68 6 21 125 M 36 33 25 126 F 75 11 27 127 F 42 22 29 128 F 46 33 23 129 F Absent Absent Excluded 130 F Absent Absent Excluded 131 M 38 14 19 132 F 28 Absent 4 133 M 55 Absent 16 134 M 49 40 7 135 M 8 14 5 136 M 45 29 13 137 M 50 63 12

Total participants 34 30 33

APPENDIX 9 – INDIVIDUAL PLAQUE SCORES ALL PARTICIPANTS

49

INDIVIDUAL PLAQUE SCORES BY WEEK - CLASS 6B

Student Code Gender

Plaque scores

Week 1 Week 2 Week 20

601 M Absent Absent Excluded 602 M 46 17 26 603 F 56 37 57 604 M 69 44 46 605 M 35 15 Absent 606 M 80 15 21 607 F 62 24 Absent 608 F 60 14 24 609 F Absent Absent Excluded 610 M 54 30 30 611 M 100 90 Absent 612 M 76 28 61 613 F 100 46 37 614 M 41 17 Absent 615 F 96 16 6 616 F 67 7 Absent 617 M Absent Absent Absent 618 F 74 54 Absent 619 M 70 9 35 620 M 80 56 15 621 M 68 21 30 622 F 67 35 26 623 F 65 49 Absent 624 F 58 22 13 625 M Absent Absent Absent 626 M 74 29 12 627 M 63 27 33 628 F 57 10 15 629 M 30 15 0 630 F 100 33 17 631 F 34 19 Absent 632 F 66 38 33 633 F 50 2 4 634 F 0 0 2 635 M 95 28 14 636 M 20 34 30 637 F 36 29 37

Total participants 33 33 25

50

INDIVIDUAL PLAQUE SCORES BY WEEK - CLASS 9B

Student Code Gender

Plaque scores

Week 1 Week 2 Week 20

901 M 31 16 9 902 F 21 12 Absent 903 M 63 25 23 904 M 26 12 13 905 M 35 23 22 906 M 94 Absent Absent 907 F Absent Absent Absent 908 F 34 19 23 909 F 67 63 Absent 910 M 18 3 10 911 M 38 25 Absent 912 F 37 25 Absent 913 M 32 29 6 914 F 58 38 Absent 915 M 36 22 41 916 F 89 22 6 917 M 24 14 28 918 F 12 9 12 919 M 63 65 38 920 F 34 21 27 921 M 54 30 15 922 F 21 1 9 923 M 1 0 2 924 F 7 1 2 925 F 14 14 12 926 F 36 20 21 927 F 40 29 Absent 928 M 13 14 12 929 F 6 7 13 930 M 44 42 19 931 M 29 36 Absent 932 F 10 2 Absent 933 M Absent Absent Excluded 934 F 27 15 27 935 F 20 5 29 936 M 26 5 17 937 M 61 66 55 938 M 24 26 2 939 M 23 7 10 940 M Absent Absent Excluded

Total participants 37 36 28

51

INDIVIDUAL PLAQUE SCORES BY WEEK - CLASS 1A

Student Code Gender

Plaque scores

Week 1 Week 2 Week 20

A01 F 0 A02 M Absent A03 F 65 A04 M 43 A05 M 49 A06 F Absent A07 M 63 A08 F 18 A09 M 24 A10 M 44 A11 F Absent A12 M 74 A13 F 70 A14 M 57 A15 M Absent A16 M 30 A17 F 56 A18 F Absent A19 F 75 A20 M 33 A21 M 50 A22 F Absent A23 F 76 A24 M 60 A25 M 71 A26 F 49 A27 F Absent A28 F Absent A29 F Absent A30 M Absent A31 F 40 A32 M 38 A33 M 33 A34 M 77 A35 F Absent A36 F 46 A37 M Absent

Total participants - - 25

52

COMMENTS ON TRIAL TOOTHPASTE* AFTER 1 WEEK – GRADE 1B

GRADE COMMENTS*

1B

Tutpeis hemi test gud tumas

Good toothpaste

Very good toothpaste

Tut peist ia i gud tumas bittim blong store

Very good when he brushes his teeth with toothpaste, we gave last week

Tut peist i gud tumas

Hemi laekem tumas tut peist hia

He really loved to use the toothpaste

Gud

I gud tumas

Tutpeist i gud

* Class 1B used the Bubble-gum flavour in the first week of the trial

COMMENTS ON TRIAL TOOTHPASTE* AFTER 1 WEEK – GRADE 6B

GRADE COMMENTS*

6B

Hemi important tumas blong get ol program olsem i happen mi bigwan long side blong brasem tut

Its good when I use the toothpaste

Toothpaste really good when I brush my teeth

Taste sweet toothpaste

Very good when I use to brush my teeth with very good taste

Trael is gud tumas mo hemi givem wan gud smile

Hemi look different long tutpeis ia wetem ol nara tutpeis, trael blong tutpeis ia i gud tumas we i helpful

Good toothpaste

Good toothpaste because it will make good oral hygiene

Hemi laekem ia from test gud

Nice toothpaste

The colour of the toothpaste is good with the taste (blue)

Like the taste of the toothpaste similar to Colgate toothpaste

Toothpaste trial is a very good flavour toothpaste that we use to brush our teeth

Really like the flavour of the toothpaste

Hemi gud blong check tut and see how it going to improve the tooth brushing

Taste nice and makes good clean of the teeth

Very good taste of the tooth paste trial

The toothpaste flavour taste very nice

* Class 6B used the Mint flavour in the first week of the trial

APPENDIX 10 – COMMENTS ON TOOTHPASTE AFTER 1 WEEK

53

COMMENTS ON TRIAL TOOTHPASTE* AFTER 1 WEEK – GRADE 9B

GRADE COMMENTS*

9B

Not even taste it yet the toothpaste

Trael ia hemi gud

Good toothpaste

It’s very good toothpaste

Good with its flavour

Good to have our own product toothpaste

Just didn't like the taste otherwise good toothpaste because you know it is produced locally

Never taste toothpaste

It’s really not the same as the other toothpaste

Just didn't like the taste of the paste

Trael ia gud tumas but no usem

Trael i gud tumas i mekem tut klin mo kilim ol bebet blong tut

Taste different similar to medicine

I gud tumas - no usem

Trael i gud no usem

Taste good but taste like warm medication

Good toothpaste but tastes similar to warm medication

I gud tumas

Trael i good tumas

Never taste but hear from others not similar to Colgate

Just the flavour not really like it

Just its flavour, not really like its flavour

* Class 9B used the Tropical flavour in the first week of the trial

54

ANY OTHER COMMENTS CONCERNING THE TRIAL – WEEK 20, ALL GRADES

GRADE COMMENTS

1B

The toothpaste was very good and also the toothpaste makes my teeth very clean. I love the toothpaste

She likes the toothpaste

When feeling pain she uses warm water and salt

The tooth brushing and the toothpaste was very helpful

When they brush, their teeth was very good and really likes the toothpaste

6B

Since the tooth brushing trial my teeth feel better than before

The toothpaste was good

The trial was very good - it will change Vanuatu and make everyone have a beautiful smile

The trial was very helpful. It helps him to continue to brush his teeth every day and also his family

Hurt when eating

Tooth brushing and the toothpaste were very good

9B

No laekem; No usem

Wan wan time when not brushing. No laekem

Tutpeist i gud but too “liquidy”

At home brushing - not in school

At home brushing - not in school

At home brushing - not in school

At home brushing - not in school

No usem

Hurt in cold weather. Extraction at VCH

Wan wan taem when drinking cold water

Brush sometimes at school

Like all flavours

No usem

No usem

APPENDIX 11 – ANY OTHER COMMENTS AT END OF PROJECT

55

Dear Barry

Many thanks for your e-mail and congratulations on undertaking the tooth-brushing trial in Vanuatu which has resulted in the new national oral health policy.

We would be very happy for you to adapt the Childsmile Programme for use in Vanuatu. The national standards for tooth-brushing are available on the Childsmile website and have been adapted by a number of countries for local use.

Attached are the two research papers which have been used as evidence to support supervised tooth-brushing in other countries.

In March last year we were asked to produce material for the website of the WHO Collaborating Centre in Malmo – a Childsmile case study. This provides a brief overview of the different components of the programme. Here is the link: https://whoeducationguidelines.org/content/childsmile-%E2%80%93-national-child-oral-health-improvement-programme-scotland

If we can be of assistance in any way as you adapt the model, please let us know – we will be delighted to share our experiences over the past 10 years.

I hope the project goes well.

Best wishes

Lorna

Professor Lorna M D Macpherson BDS, MPH, PhD, FDS, FRCD(C), FFPH, FHEA, FRSE Professor of Dental Public Health Deputy Head of the Dental School University of Glasgow Dental School 378 Sauchiehall Street Glasgow, G2 3JZ Tel: 0141 211 9751 The University of Glasgow, charity no. SC004401

From: Barry & Evelyn Stewart [mailto:b_estewart@bigpond.com] Sent: 28 December 2018 00:55 To: Lorna Macpherson Subject: Childsmile Dear Professor Macpherson,

I am a retired dentist from Melbourne, Australia working in a voluntary capacity for Medical Sailing Ministries http://msm.org.au/, which in turn works with PCV Health in Vanuatu http://pcvhealth.org/.

In 2017 I led a National Oral Health Survey of Vanuatu following the WHO, Oral Health Surveys, Basic Methods, 5th Edition, and the 195-page report was recently submitted to the Vanuatu Government on November 15th. As a result Vanuatu now has its first-ever National Oral Health Policy.

One of the findings from the survey revealed that 40% of 5-7-year-old children either rarely or never brushed their teeth. Therefore in 2018 I conducted a 20-week supervised tooth-brushing trial in Grades 1, 6 and 9 children at a Port Vila school in order to demonstrate a simple oral health prevention program. The name of the trial was “Gudfala Tut Skul Projek” (=Healthy Tooth School Project), and I am pleased to report that each of the grades achieved significant reductions in plaque scores over the period of the trial.

I am now preparing a second report to the Government of Vanuatu to support introduction of one of the key recommendations of the National Oral Health Survey i.e., supervised tooth brushing in kindergarten and primary schools (initially in Kindergarten levels 1 and 2 and Grade 1 students).

During my search for background material I came across the amazing Childsmile Programme and it I believe that this model would be ideal for adaptation to Vanuatu.

I would very much appreciate your permission to adapt the Childsmile Programme for use in Vanuatu as it would expedite earlier delivery of the “Gudfala Tut Skul Projek”.

I have attached a Report Summary and Fact Sheet on some of the major findings from the survey.

The full report can be accessed via the following link https://www.dropbox.com/s/3phb52ks0puvbgv/NOHS%202017%20Report%20Final%20Summary.pdf?dl=0 The Gudfala Tut Skul Projek is mentioned briefly on pp. 115-118.

Yours sincerely,

Barry Stewart

APPENDIX 12 – CORRESPONDENCE, PROF LORNA MACPHERSON, CHILDSMILE

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4. Macpherson LMD, Anopa Y, Conway DI, McMahon AD.National Supervised Toothbrushing

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5. Childsmile Manual for Childsmile Staff. July 2016. http://www.child-

smile.org.uk/uploads/documents/4531-

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departments/dental-academy/Supervised-tooth-brushing-handbook.pdf Accessed March 2019

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13. Walsh T et al., (2010). Fluoride toothpastes of different concentrations for preventing dental caries in children and adolescents. Cochrane Database Syst Rev, (1):CD007868.

14. Twetman S et al., (2003). Caries-preventive effect of fluoride toothpaste: a systematic review. Acta Odontol Scand, 61(6):347–355.

APPENDIX 12 – REFERENCES

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